Health Service Provider Planning and DevelopmentUnder the Act, Part 1

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1 Local Health Integration Network / Health Service Provider Governance Resource and Toolkit for Voluntary Integration Initiatives December 15, 2008

2 Local Health Integration Network/ Health Service Provider Governance Resource and Toolkit for Voluntary Integration Initiatives December 15, 2008

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4 Table of Contents Acknowledgements... v Glossary of Terms... vii Introduction to the Toolkit... ix Background... ix Purpose... x Sponsorship of Toolkit... xi Contents of Toolkit... xi Part 1 The Relationship Between LHIN and Health Service Provider Boards... 1 Section 1 The Act s Requirements For Voluntary Integration Initiatives... 3 Introduction... 3 The Rules...3 Relevant Sections of the Act... 8 Section 2 LHIN Expectations for Board Oversight of Voluntary Integration Initiatives... 9 Introduction... 9 Expectations of the LHIN Board... 9 Expectations of the Health Service Provider Board Section 3 LHIN Decision-Making Processes and Evaluation Criteria Introduction Decision-Making Process Evaluation Criteria Section 4 Approaches to Community Engagement Introduction Definition of Community Engagement Approaches to Community Engagement by LHINs Approaches to Community Engagement by Health Service Providers Section 5 LHIN-Health Service Provider Governance Relationships Introduction Rationale for Establishing a Governance Relationship between LHIN and Health Service Provider Boards Considerations for Establishing LHIN/Health Service Provider Governance Relationships24 Sample Terms of Reference and Related Documents (iii)

5 Part 2 Health Service Provider Board Leadership Section 1 Health Service Provider Board Accountability for Voluntary Integration Initiatives Introduction Board Roles and Responsibilities Corporate Structures and Delegation of Authority Sample Board Policy and Checklists Section 2 Health Service Provider Board Involvement in a Voluntary Integration Initiative Introduction Board Involvement in Voluntary Integration Initiatives: A Continuum Approaches to Board Interaction Section 3 Key Success Factors for Board Collaboration in Voluntary Integration Initiatives Introduction Facilitation Tools for Successful Meetings Section 4 Possible Integration Mechanisms Introduction Possible Mechanisms for Integration Section 5 Sample Partnering Agreement between Health Service Providers on Voluntary Integration Initiatives Introduction Checklist Section 6 Measuring the Success of a Voluntary Integration Initiative Introduction Integration Goals Processes and Key Performance Indicators to Measure the Success of the Voluntary Integration Initiative Other Available Resources (iv)

6 Acknowledgements The following individuals participated in the development of this Toolkit. Project Steering Committee Members Ken Morrison, Chair, Project Steering Committee and Board Chair Central LHIN Dan Burns, Ontario Health Providers Alliance Long-Term Care Ruthe-Anne Conyngham, Ontario Health Providers Alliance Ontario Hospital Association Judith Hayward, Chair, Ontario Association of Community Care Access Centres Michael Hurry, Vice-Chair, Erie St. Clair LHIN Foster Loucks, Board Chair, Central East LHIN Kathryn McCulloch, Manager LHIN Liaison Branch West Unit, Ministry of Health and Long-Term Care Diane McLeod, Chair, Ontario Health Providers Alliance Joe McReynolds, Board Chair, Central West LHIN Georgina Thompson, Board Chair, South East LHIN Laura Visser, Ontario Health Providers Alliance Community Support Services Project Team Members Maureen Quigley, Maureen Quigley & Associates Inc. Graham Scott, Graham Scott Strategies Inc. and Counsel to McMillan LLP Lydia Wakulowsky, Partner and Chair, Health Law Group, McMillan LLP (v)

7 Associations Canadian Mental Health Association Associations of Ontario Health Centres Ontario Federation of Community Mental Health and Addiction Programs Ontario Association of Non-Profit Homes and Services for Seniors (vi)

8 Glossary of Terms Terms used in this Toolkit have the following meanings: Act means the Local Health System Integration Act, Board means a board of directors. collaborate and collaboration means a mutually beneficial well-defined relationship entered into by two or more organizations to achieve common goals. Collaboration is the process of various individuals, groups or systems working together but at a significantly higher degree than through co-ordination or co-operation. Collaboration typically involves joint planning, shared resources and joint resource management. Collaboration occurs through shared understanding of the issues, open communication, mutual trust and tolerance of differing points of view. To collaborate is to co-labor. community, in the context of LHIN community engagement, means patients, other individuals in the LHIN s geographic area, health service providers, other providers that provide services in or for the local health system, and employees involved in the local health system. health service provider means the following persons and entities: 1. a person or entity that operates a public hospital under the Public Hospitals Act or a private hospital under the Private Hospitals Act, 2. a person or entity that operates a psychiatric facility under the Mental Health Act, unless the facility is an institution under the Mental Hospitals Act, a correctional institution operated or maintained by Cabinet other than the Minister or a federal prison or penitentiary, 3. The University of Ottawa Heart Institute, 4. an approved corporation that operates and maintains an approved charitable home for the aged under the Charitable Institutions Act, 5. each municipality or a board of management maintaining a home for the aged or a joint home for the aged under the Homes for the Aged and Rest Homes Act, 6. a licensee under the Nursing Homes Act, 7. a community care access corporation within the meaning of the Community Care Access Corporations Act, 2001, 8. a person or entity approved under the Long-Term Care Act, 1994 to provide community services, 9. a not-for-profit corporation that operates a community health centre, 10. a not-for-profit entity that provides community mental health and addiction services, and 11. any other person or entity or class of persons or entities cited in the regulations. (vii)

9 Health System Improvement Pre-proposal and H-SIP means the process established by the LHINs to assist them in making a preliminary assessment of any request or activity contemplated by a health service provider that requires LHIN approval. integrate and integration includes: to co-ordinate services and interactions between different persons and entities, to partner with another person or entity in providing services or in operating, to transfer, merge or amalgamate services, operations, persons or entities, to start or cease providing services, and to cease to operate or to dissolve or wind up the operation of a person or entity. integrated health service plan means the plan that a LHIN develops under section 15 of the Act for the local health system. LHIN means a local health integration network. local health system means the part of the health system that provides services in the geographic area of a LHIN, whether or not the services are provided to people who reside in the geographic area. Minister means the Minister of Health and Long-Term Care. Ministry means the Ministry of Health and Long-Term Care. Service Accountability Agreement means the service accountability agreement that a LHIN and a health service provider are required to enter into under section 20(1) of the Act. service, for the purpose of voluntary integration initiatives, means: a. a service or program provided directly to people (e.g. health care service), b. a service or program that supports a health care service (e.g. ancillary service), or c. a function that supports a health service provider (e.g. back office service). voluntary integration initiative, as used in this Toolkit, means integration activities voluntarily initiated by health service providers. (viii)

10 Introduction to the Toolkit This material provides general information only, and should not be relied upon as legal advice or opinion. The contents of this document are subject to the interpretation of the Local Health System Integration Act, 2006 by the Courts and Boards of Arbitration, subject to other applicable legislation, and subject to existing (and future) obligations under relevant collective agreements and your Service Accountability Agreement. It should also be noted that all notice and consultation provisions in your collective agreements will still need to be followed. It is strongly recommended that in the event of a voluntary integration initiative, the appropriate human resource professionals are consulted and independent legal advice is sought, in order to ensure compliance with the Local Health System Integration Act, 2006, other legislation, your Service Accountability Agreement, and the relevant collective agreements. Background The Local Health System Integration Act, 2006 (the Act ) was passed to: provide for an integrated health system to improve the health of Ontarians through better access to high quality health services, co-ordinated health care in local health systems and across the province and effective and efficient management of the health system at the local level by local health integration networks. 1 Under the Act, LHINs are charged with the planning, funding and integration of the local health system, including the following health service providers: long-term care facilities, community care access corporations, hospitals, community support services, community health centres, and addiction and mental health agencies. The Act has resulted in two levels of governance of the local health system system level governance (the responsibility of the LHIN) and organizational level governance (the responsibility of the health service provider). This has led to new expectations by the Ministry and the LHINs in how services are to be planned, managed and delivered. These new expectations have led to the need for strategic dialogue between LHIN and health service provider Boards and among health service provider Boards. 1 Local Health System Integration Act, 2006, S.O. 2006, c. 4, Section 1. The official legal text of the Act is available at < (ix)

11 Integration of the health system provides the principal rationale for the Act. The successful implementation of integration initiatives will constitute a challenge for both LHINs and health service providers. While the Act provides LHINs with the absolute authority to require health service providers within their geographic areas to integrate 2, it also places a direct responsibility on health service providers, separately and in conjunction with the LHINs, to identify integration opportunities. To ensure that health service providers develop voluntary integration initiatives acceptable to their LHINs, co-operation and collaboration between LHINs and health service providers and among health service providers is essential. LHIN and health service provider Boards share a common interest in working together. Many voluntary integration initiatives might require new relationships and realignment of services that have operational implications for human and financial resources and facility utilization that will require considerable skill in their planning and execution. In this environment, it is essential that there is effective Board leadership to demonstrate commitment, collaboration and community engagement to ensure voluntary integration initiatives achieve their intended goals. Purpose LHIN Boards have established a variety of processes to engage in strategic dialogue with health service provider Boards on approaches to implement their respective integrated health service plans, including use of voluntary integration initiatives. This has resulted in a recognition of the need for a resource and sample tools for health service provider Boards to: assist health service provider Boards to understand evolving LHIN practices, processes and expectations arising from interpretation and application of the Act, as illustrated by the experience of the participating LHINs, and support health service provider Boards in understanding their respective roles and responsibilities, in providing appropriate leadership to their organizations and in developing strategies to work with one another and with the LHIN Boards on voluntary integration initiatives. Ultimately, it is intended to maximize health service providers opportunities to initiate voluntary integration initiatives that are aligned with LHIN expectations rather than to be left to respond to LHIN or Ministerial ordered integration. Significant diversity in the size, corporate structures and governance approaches between and among the various health service providers leads to considerable challenges and defies any cookie cutter approach to Board governance. Recognizing this diversity, the guidance provided by this Toolkit is intended to assist the range of health service provider Boards in addressing their 2 Integrate is defined on page viii. This Toolkit is intended to support health service provider Boards in understanding their respective roles and responsibilities, in providing appropriate leadership to their organizations and in developing strategies to work with one another and the LHIN Boards on voluntary integration initiatives. (x)

12 responsibilities and in working through the governance complexities and uncertainties inherent in the identification, development and implementation of voluntary integration initiatives. This Toolkit is a governance tool for health service provider Boards. Detailed operational information on LHIN planning processes and requirements related to voluntary integration and other types of integration is beyond the scope of this document but can be obtained from the Ministry Reference Guide to the Act and from each individual LHIN. 3 Sponsorship of Toolkit This Toolkit has been co-sponsored by a Project Steering Committee, whose members are: the Board Chairs of five LHINs, being the Central LHIN, Central East LHIN, Central West LHIN, Erie-St. Clair LHIN and South East LHIN, the Chair and three health service provider Board representatives of the Ontario Health Provider Alliance, a Board representative of the Ontario Association of Community Care Access Centres, and a representative of the LHIN Liaison Branch of the Ministry of Health and Long-Term Care. Contents of Toolkit Part 1 The Relationship Between LHIN and Health Service Provider Boards addresses the relationship between LHIN and health service provider Boards in voluntary integration initiatives. In recognition of the early stages of LHIN development, and the evolving experience of LHINs and health service providers in generating and dealing with integration proposals, Part 1 has been developed as a collection of approaches and examples of processes used by contributing LHINs to implement integration across their health systems. It is not intended to be a policy document or interpretation of the Act being applied to all LHINs. Section 1 summarizes the Act s requirements for health service providers concerning voluntary integration activities. Section 2 illustrates LHIN expectations for LHIN and health service provider Board oversight of planning, development, approval, implementation and follow-up assessment of voluntary integration initiatives. Section 3 provides examples of LHIN decision-making processes and evaluation criteria for voluntary integration initiatives. 3 See Ministry of Health and Long-Term Care/LHIN Working Group, Reference Guide to the Local Health System Integration Act, 2006: Integration, Labour Relations and Devolution, December 2007 found in Appendix (xi)

13 Section 4 provides examples of LHIN expectations concerning approaches to community engagement. Section 5 provides examples of LHIN/health service provider governance relationships. Section 1 of Part 1 was developed by the Project Team. Sections 2 through 5 were developed by the LHIN members of the Project Steering Committee. Part 2 Health Service Provider Board Leadership supports health service provider Boards in providing appropriate leadership to their organizations and, where appropriate, in working effectively together at the Board level with other health service provider Boards to achieve a broader health system approach toward the identification, development and implementation of joint voluntary integration initiatives. The checklists, templates and tools provided in Part 2 are not meant to be prescriptive. They are provided as recommended best practices for you to consider implementing, as adapted to suit the particular circumstances of your organization. Section 1 addresses health service provider Boards accountability for voluntary integration initiatives and provides a sample Board policy and checklists designed to assist Boards in ensuring compliance with the Act, LHIN expectations and strategic plans. Section 2 addresses the continuum of health service provider Board involvement in the identification, development and implementation of voluntary integration initiatives, describes possible mechanisms for interaction between health service provider Boards and provides sample Terms of Reference for a Joint Health Service Provider Board Task Force. Section 3 identifies some key success factors for collaboration at the Board level among representatives of health service provider Boards where direct Board to Board involvement is appropriate in identifying, developing and implementing voluntary integration initiatives. Section 4 describes some possible mechanisms to implement the different kinds of integration activities identified in the Act and is intended to assist health service provider Boards in understanding what is possible along the continuum of arrangements from informal to formal. Section 5 provides a checklist for, and an example of, a partnering agreement between health service providers on a voluntary integration initiative. Section 6 addresses how to measure the success of a voluntary integration initiative. Sections 1 through 6 were developed by the Project Team. (xii)

14 Part 1 The Relationship Between LHIN and Health Service Provider Boards Part 1 of this Toolkit addresses the relationship between LHIN and health service provider Boards in voluntary integration initiatives. In recognition of the early stages of LHIN development, and the evolving experience of LHINs and health service providers in generating and dealing with integration proposals, Part 1 has been developed as a collection of approaches and examples of processes used by contributing LHINs to implement integration across their health systems. It is not intended to be a policy document or interpretation of the Act being applied to all LHINs.

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16 Section 1 The Act s Requirements For Voluntary Integration Initiatives Introduction As defined in the Act, integrate and integration includes: to co-ordinate services and interactions between different persons and entities, to partner with another person or entity in providing services or in operating, to transfer, merge or amalgamate services, operations, persons or entities, to start or cease providing services, and to cease to operate or to dissolve or wind up the operation of a person or entity. Integration activities can be: self initiated by a health service provider under sections 24 and 27 of the Act ( voluntary integration initiatives ), facilitated and negotiated by a LHIN under section 25 of the Act, resulting from changes in funding under section 19 of the Act, required by a LHIN under section 26 of the Act, or ordered by the Minister under section 28 of the Act. This section summarizes the rights and obligations of health service providers concerning voluntary integration initiatives. 4 The Rules Planning and Community Engagement Under section 16(6) of the Act, health service providers must engage the community of diverse persons and entities where they provide services when they develop plans and set priorities. The Act does not define community of diverse persons and entities for health service providers. Some guidance is found in section 16(2) of the Act, which defines the LHIN community as: 4 See Local Health System Integration Act, 2006, S.O. 2006, c. 4 at 3

17 patients and other individuals in the LHIN s geographic area, health service providers and others that provide services in or for the local health system, and employees involved in the local health system. Some LHINs interpret the health service provider community to also include funders. 5 Regardless of their size, budget or mandate, in many instances health service providers will engage their community when they develop plans for voluntary integration initiatives. The Act, however, does not prescribe when or how such community engagement must take place. Suggestions for community engagement approaches are outlined in Part 1, Section 4 of this Toolkit. Voluntary Integration Initiatives Under the Act, all health service providers must identify opportunities to integrate the services of the local health system for the purpose of providing appropriate, coordinated, effective and efficient services. Health service providers must perform this obligation both individually and collectively with the LHINs. A health service provider may integrate its services with another health service provider or with another person or entity. 6 Health System Improvement Pre-proposal (H-SIP) Process 7 After the Act was passed, the LHINs developed a Health System Improvement Preproposal or H-SIP process, which is meant to enable: health service providers to gauge the LHIN s concerns early in the development stage of the voluntary integration initiative, and LHINs to make a preliminary assessment of any voluntary integration initiative proposed by health service providers. The H-SIP process is meant to take place before a health service provider files a Notice of Integration under section 27 of the Act. Please refer to Part 1, Section 3 of this Toolkit and to Appendix for details on the H-SIP process. The Act s requirements and processes for voluntary integration initiatives are summarized below. 5 See Part 1, Section 4 of this Toolkit at page See Part 2, Section 4 for a description of possible integration mechanisms and Part 2, Section 2 for some examples of integration. 7 The H-SIP process does not form part of the Act. 4

18 Notice of Integration to the LHIN If a health service provider wishes to integrate its services with those of another person or entity and if the proposed integration relates to services that the LHIN funds (in whole or in part), the health service provider must first give notice of the proposed integration to the LHIN ( Notice of Integration ). 8 If the proposed integration relates to services that are not funded by the LHIN, then no such notice is required and the health service provider may proceed with the integration. For example, two community mental health agencies that receive funding for certain services from the Ministry of Community and Social Services would not need to inform the LHIN if they wished to integrate those services by creating a common referral and outreach centre. 9 The Act has an exception to the Notice of Integration requirement by allowing for the development of a regulation that would exempt certain kinds of integration. No such regulations exist on the date of publication of this Toolkit. If such a regulation were made, however, a health service provider could proceed with an intended integration that fell into the exemption without providing the Notice of Integration to the LHIN. When the health service provider gives a Notice of Integration to the LHIN, it triggers a series of processes, requirements and rights, described below. LHIN Consideration of Proposed Integration Once a LHIN receives a Notice of Integration from a health service provider, the LHIN may consider if the proposed integration is in the public interest. This will include consideration of whether the proposed integration is consistent with the LHIN s integrated health service plan and any other relevant matter. 10 If the LHIN determines that the proposed integration is not in the public interest, the LHIN has the power to order the health service provider not to proceed with the integration. In this way, the LHIN can ensure that integration activities are conducted for the benefit of the local health system as a whole. If the LHIN determines that the proposed integration is in the public interest, it may choose to take no action or to notify the health service provider that it does not intend to issue a decision stopping the integration. 8 A template for this notice is found in Appendix at pages See footnote 3 at page A list of examples of what the LHIN would consider to be in the public interest is found in Appendix at pages

19 A LHIN s decision not to stop a proposed integration concerning LHIN-funded services does not prevent the LHIN from facilitating or negotiating the integration nor does it prevent the LHIN from issuing a decision requiring the parties to undertake certain integration activities in relation to the proposed integration. LHIN Process Where it has Concerns about the Proposed Integration A LHIN can prevent the integration or a part of it from proceeding if it has concerns about it. In doing so, the LHIN would follow this process: The LHIN would, within 60 days of receiving the Notice of Integration, provide the health service provider with a notice that it proposes to issue a decision ( Section 27 Decision ) 11 ordering the health service provider not to proceed with the integration or a part of it. The LHIN would provide the health service provider with a copy of the proposed Section 27 Decision and would make a copy of it available to the public. > When the LHIN issues a proposed Section 27 Decision, a health service provider or any other person may make written submissions about it within 30 days of the LHIN making it available to the public. This provides an opportunity for any interested party to provide input to the LHIN. The LHIN may set conditions on the integration; that is, order the health service provider not to proceed with the integration (or a part of it) unless certain conditions are met. > If the LHIN issues a Section 27 Decision ordering a health service provider not to proceed with a part of the proposed integration or if the LHIN sets conditions on the integration, the health service provider may choose not to proceed with any part of the proposed integration. 12 If more than 30 days but no more than 60 days have passed after the LHIN provides the health service provider with a notice that it proposes to issue a Section 27 Decision and after the LHIN has considered any written submissions received about it, the LHIN may, if it considers it in the public interest to do so, issue a Section 27 Decision. > A Section 27 Decision may be different from the proposed decision described in the notice of Section 27 Decision. Proceeding or Not Proceeding with Integration If the LHIN does not provide the health service provider with a notice that it intends to issue a Section 27 Decision, the health service provider must wait until 60 days have passed since the 11 A template Section 27 Decision is found in Appendix at pages See Appendix at page 26. 6

20 health service provider gave the Notice of Integration to the LHIN before proceeding with the integration. If the LHIN does provide the health service provider with a notice that it intends to issue a Section 27 Decision, the health service provider must then wait until 60 days have passed since the LHIN gave that notice. If the LHIN issues a Section 27 Decision, then the health service provider must not proceed with the integration and must comply with the Section 27 Decision. The Act gives: health services providers the necessary powers to comply with the Section 27 Decision, and the LHIN the power to seek a court order requiring a health service provider to comply with the Section 27 Decision. A flowchart on the required process is attached at Appendix at pages 28 and LHIN Involvement in Integration Activities through Negotiation or Facilitation The LHIN could become involved in an integration activity voluntarily initiated by one or more health service providers by assisting with negotiation or facilitation of the activity. When a LHIN negotiates or facilitates the integration of entities, at least one of the entities must be a health service provider but not all those involved need to be. When a LHIN negotiates or facilitates the integration of services, this can be done between two or more health services providers or between a health service provider and another entity, if the parties reach an agreement. The LHIN may advise the public and other stakeholders about a negotiated or facilitated integration but it is not required to do so. There may be circumstances where public input is particularly important and other circumstances where the nature of the negotiation warrants greater confidentiality. The LHIN would exercise its best judgment in weighing the principles of transparency and consultation with the need for confidentiality in the particular situation. 14 The LHIN must issue an integration decision when it has facilitated or negotiated an integration that the parties have agreed upon. 13 See footnote 3 at pages 23 and See footnote 3 at page 14. 7

21 Relevant Sections of the Act Section 2 (Definitions), particularly: Act, health service provider, integrated health service plan, integration, LHIN, services Part II (LHINs), section 5(a) (Objects) Part V (Integration), sections 16, 23, 24, 25, 27, 29 8

22 Section 2 LHIN Expectations for Board Oversight of Voluntary Integration Initiatives Introduction LHINs have been given the responsibility of implementing some critical components of Ontario s health system transformation. The LHINs combined responsibilities of planning, funding, coordinating and integrating the services of six major health service provider sectors in the system have inherent contradictions and competing forces. To achieve the system improvement and efficiency anticipated from integration, organizations need to remove the functional silos among them, and to work together to share information and coordinate services. This section outlines LHIN expectations for LHIN and health service provider Board oversight of planning, development, approval, implementation and followup assessment of voluntary integration initiatives. 15 Expectations of the LHIN Board Expectations concerning the roles and responsibilities of the LHIN Board include functioning in an open and transparent manner to: produce and disseminate an integrated health service plan in broad consultation with the community, which includes: > patients/clients and other individuals in the LHIN geographic area, > health service providers and other persons or entities that provide services in or for the local health system, and > employees involved in the local health system, enable and leverage integration by virtue of the LHIN s planning, coordinating and funding roles, ensure the LHIN focuses on productive and effective integration initiatives (as opposed to creating administrative barriers), 15 These expectations reflect the perspectives of the participating LHINs, and do not constitute policy for all LHINs across the province. Health service providers should contact their respective LHINs for additional information. 9

23 ensure appropriate voluntary integration initiatives are implemented, monitored and refined as necessary to achieve proposed benefits and outcomes, amend LHIN-health service provider service accountability agreements to reflect voluntary integration initiatives and resultant responsibilities, and develop and disseminate a policy to provide clear indication of consequences arising from non-participation or lack of implementation of voluntary integration initiatives (e.g. funding reallocations). Expectations of the Health Service Provider Board Expectations concerning the roles and responsibilities of the health service provider Board, as contemplated under the Act, include: (a) (b) (c) (d) (e) ensure proposed voluntary integration initiatives are approved by the Board and submitted to the LHIN, ensure consultation in collaboration with the LHIN and the community for voluntary integration initiatives, ensure staff develop proposals for voluntary integration initiatives consistent with the integrated health service plan and prescribed LHIN processes, join with their LHIN to execute appropriate amendments to the service accountability agreement to reflect voluntary integration initiatives, and monitor, evaluate and amend voluntary integration initiatives as required to achieve proposed benefits and outcomes. Suggested governance oversight questions for a health service provider Board to its management leadership on a regular basis include: 1. Are there any changes being proposed to our programs and services that would constitute an integration under the Act? 2. What specific programs, services or actions have been selected for implementation of the integrated health service plan in collaboration with our LHIN partners (including the LHIN, other health service providers and other persons and entities) and the community we serve? 3. What results have been achieved to meet our responsibilities for integration as described in the Act and our service accountability agreement with the LHIN? 10

24 Section 3 LHIN Decision-Making Processes and Evaluation Criteria 16 Introduction When developing and approving voluntary integration proposals, it is important for health service provider Boards, CEOs and planning staff to understand the decision-making process and evaluation criteria used by their particular LHIN so that they are better able and positioned to align their proposals with the direction and priorities of the LHIN. This section identifies a decision-making process and evaluation criteria in use by LHIN Boards and staff participating in the development of this Toolkit to guide fair, transparent and consistent consideration of voluntary integration initiatives. Decision-Making Process In Spring 2007, the LHIN CEOs developed a common tool, the Health Service Improvement Pre-proposal ( H-SIP ) for the identification of health service improvement initiatives (including integration) by health service providers. 17 The first step in the decision-making process for all LHINs is the receipt and review of the H-SIP form from the sponsoring health service provider(s). Upon receipt of an H-SIP form, LHIN staff will review the information outlined in the form. Dependent upon LHIN staff s preliminary evaluation of that information, the LHIN will followup with the health service provider on its estimate of the value of pursuing the voluntary integration initiative and the LHIN s requirements for additional information or expanded partnering arrangements. LHIN staff and health service providers may work together to ensure that due diligence is undertaken to positively support their LHIN s decision-making framework. LHINs do not have a common decision-making framework, however, the framework will reflect the requirements of the Act, and support the individual integrated health service plan. Upon completion of the planning and development process, the health service provider will then submit a Notice of Integration to the LHIN under the Act, and the supporting materials will be brought to the LHIN Board for consideration within the timeframe allowed under the Act. The process described in Part 1, Section 1 will then be followed. In Fall 2007, Central LHIN health service providers requested assistance from the Central LHIN in determining what constituted a Notice of Integration requiring LHIN Board consideration 16 These expectations reflect the perspectives of the participating LHINs, and do not constitute policy for all LHINs across the province. Health service providers should contact their respective LHINs for additional information. 17 This tool may be accessed through the public websites of all LHINs. 11

25 under the Act. In response, the Central LHIN developed Guidelines for Identifying Integration Proposals. 18 A LHIN-Ministry workgroup also developed materials for use by LHIN Boards and staff to support integration. In September 2007, an Integration, Labour Relations, and Devolution document was developed to provide the legislative context and policy intent for integration activities. 19 There is a plan to create a public central repository of approved integration decisions that all LHINs would be able to access to monitor activities throughout the provincial healthcare system. Evaluation Criteria The H-SIP form outlines general information to be supplied by a health service provider to the LHIN, including contact information, a project summary, whether a capital component is required, the project s alignment with the integrated health service plan, the project s rationale, benefit to the community, collaboration, sustainability and funding requirements. The H-SIP process is intended to support health service providers in submitting proposals across LHINs and to provide some general information on the factors on which the proposal will be evaluated in order to move to the next phase of the decision-making process. The H-SIP process is to be used by health service providers to request new funding, reallocation of funding, as well as integration. Building on the stated purpose of the Act 20 and subsequent Ministry guidance to the LHINs, voluntary integration initiatives should at a minimum include or result in: improved access and quality of care, coordinated healthcare, improved navigation through the continuum of care, effective and efficient service delivery, alignment with the integrated health service plan, and a consideration of the public interest. 18 This document is posted on the Central LHIN website. 19 See Appendix See footnote 1, page ix and footnote 3, page xi. 12

26 Materials reviewed from other LHINs indicate that the LHINs are applying the above-noted criteria. Additional evaluation criteria might be applied by each LHIN reflecting the priorities of the local integrated health service plan. For example, the four System Goals of the Central LHIN are the main criteria against which voluntary integration proposals will be assessed: access, coordination, quality and efficiency. Factors that have been developed by the Central LHIN to further consider in each criterion include: Access: > volumes relative to population health indicators, > wait times relative to provincial targets, > distance (for primary, secondary or tertiary services), and > choice. Coordination: > Does the proposal advance coordination and collaboration? > Has the continuity and coordination of services for the patient/client across the continuum of care been improved or adequately addressed? > Have impacts on other affected services been addressed and improved (e.g. emergency departments)? > Have impacts on complementary services been addressed and improved (e.g. obstetrics and paediatrics)? > Is there a positive impact on the local health system? Quality: > consistency with patient/client centred health care, > patient/client and workforce safety, > critical mass for program competence and sustainability, > evidence of clinical best practice and high health outcomes, > defined responsibility for system, organizational and clinician quality, and > quality measurement plan. 13

27 Efficiency: > impact on use of resources and health system sustainability, > cost (initial and ongoing) and availability of resources, > cost-benefit (e.g. the greater the volume, the lower the price), and > impact on labour and employment relations. Further to that, the principles that help guide the decision-making process may include: No surprises the purpose of the H-SIP form is to identify integration opportunities at a very early stage in the process, to inform the LHIN of the potential partnership, and to ensure that due diligence requirements are met by both the LHIN and the health service provider. Ethical. Equity equity does not deal with the issue of ideal supply of services, but rather about levelling the field, even when services are in short supply. Ensure that any one person s level of access is reasonable relative to all others who need the service. Diversity or cultural competence. Public accountability and transparency. Alignment with provincial priorities. Cooperation and coordination. Innovation may include partnerships with non-traditional and/or private providers. Evidence-based decision making ensures that decisions about health and health care are based on the best available knowledge. The Central LHIN has developed a decision tool to further evaluate proposals and their impact on the population affected and the funding requirements as well as strong patient/client focus, quality and safety, motivation and readiness, level of health risk mitigated, resource requirements, clarity in roles of partners, working relationships and health human resources. The Toronto Central LHIN includes additional criteria for inclusiveness and responsiveness, accountability for outcomes, stability and continuous improvement, quality of life and participation in society, and building support to help people, especially seniors, stay in their homes and communities as long as possible. 14

28 Section 4 Approaches to Community Engagement 21 Introduction The Ontario model of devolution of health care management is unique in that community-based volunteer governance of health service providers has been left intact. This is because the government recognizes the valuable diversity of experience and perspectives offered by community members to their local Boards. LHINs present a new opportunity for health service provider Boards to build and strengthen relationships and networks across the system. This section reviews evolving LHIN approaches to community engagement and LHIN expectations for community engagement by health service provider Boards and provides some tools for consideration in the development of community engagement strategies. Definition of Community Engagement Community engagement is a complex undertaking that employs different tools and processes to inform the community and obtain input, feedback and validation from the community. Community, for the purpose of community engagement by the LHIN, has been defined in section 16(2) of the Act as: (a) (b) patients and other individuals in the geographic area of the LHIN, health service providers and any other person or entity that provides services in or for the local health system, and (c) employees involved in the local health system. 22 There is no similar provision in the Act concerning the extent of engagement required by health service providers. An inclusive definition in line with the Act s definition is to consider community engagement as involving all those members/stakeholders of the healthcare community, including health service providers, health care professionals, patients/clients, consumer support groups, funders and residents in broad health care planning. 21 These expectations reflect the perspectives of the participating LHINs, and do not constitute policy for all LHINs across the province. Health service providers should contact their respective LHINs for additional information. 22 Health service providers are encouraged to familiarize themselves with the judgment of the Ontario Superior Court of Justice (Divisional Court) in Ontario Public Service Employees Union v. Central East LHIN and Rouge Valley Health System (August 22, 2008). 15

29 Engagement thus most effectively happens at all levels, from governance to the front lines and community residents. Engagement unlocks and leverages system planning expertise to create real solutions; incorporates knowledge about health needs, experiences and satisfaction; provides a means for emerging trends to be identified; and ultimately can stimulate collective responsibility towards the health system. Approaches to Community Engagement by LHINs Section 16(1) of the Act states that a local health integration network shall engage the community of diverse persons and entities involved with the local health system about that system on an ongoing basis, including about the integrated health services plan and while setting priorities. As a result, LHIN Boards play an active and direct role in engaging the community. LHIN Boards, alone and occasionally with health service provider Boards, will engage: elected representatives, cultural and community leaders, and French language and Aboriginal and First Nations Peoples and health planning entities, and the community directly on specific issues that have a resonance with the public. The purpose of this engagement is to develop local intelligence on emerging issues, strategic directions, and issues and barriers to equitable access. Engagement processes are developed based upon local need and capacity, and may include focus groups, task/working groups, open forums, advisory bodies and town halls. There are different approaches and techniques to engagement, each one may be appropriate for different engagement objectives, outcomes and capacities. The table below provides a sample framework of techniques and levels of engagement developed by the Central East LHIN. These various approaches are not mutually exclusive, nor are they meant to represent a checklist of techniques. Instead, these approaches should be seen as a tool-kit of community engagement practices across a continuum. In general, the more complex the issue, and the greater the need for stakeholder buy-in, the more multi-faceted the engagement activities should become. 16

30 Table 1: The Levels and Toolbox of Engagement 23 Irrespective of the engagement method employed, there will be a consistent commitment to the following principles and purposes. 23 Source: 17

31 LHIN Goals To renew and maintain a focus on the people who use health care Our health system is owned and used by the people of Ontario, yet so often we lose focus on who the system is designed to serve. A patient/client focused health system must engage the end-user in the planning process as they are most knowledgeable about their needs, experience and satisfaction with health care services. Enhance local responsiveness and accountability Engagement will enhance accountability at the local level by improving transparency and providing direct opportunities for input into decision-making. Furthermore, in promoting shared accountability for the coordination of service delivery and consumer outcomes, the LHIN will spread ownership through involvement. Balance priorities Informing and engaging the public is the best approach to address community needs and responsibilities. Health care is a complex web of interdependencies. Through dialogue we aim to foster a shared understanding and balance amongst competing priorities. Develop system capacity and sustainability Communities are the best source of knowledge about their own needs and their own solutions. We will harness this knowledge and capacity to identify needs and gaps, and help build sustainable, long term solutions. Where necessary, we will work with our partners to enhance their capacity for collaborative consultation. Build confidence in our public health care Ontario has world class health care made possible by the tireless efforts of front-line health providers, administrators and volunteers. By engaging the community we not only learn, but start to mould a new culture of awareness, behaviour and coordinated action that is necessary for public confidence in the health system. Other Key Objectives In addition to the broad goals outlined above, the LHIN needs to accomplish other practical but essential objectives: To fulfill the LHIN mandate to engage the community in regional health system priority setting and planning. To work directly with the community to ensure that community concerns are consistently understood and considered, and to gather intelligence and leverage expertise in local challenges and opportunities to improve access to consumer care, the integration of health services, and the overall effectiveness of the health system. To leverage expertise and people in the development, implementation, and evaluation of the integrated health services plan. To provide the community with balanced and objective information to assist them in understanding the role and mandate of the LHIN and the responsibilities and expectations of all stakeholders. To confirm the role of current and future advisory networks with the LHIN. 18

32 To coordinate LHIN plans for community consultation with existing processes in use with health service providers and their Boards, health councils or other representative entities. Community/Stakeholder Engagement Frameworks Each LHIN has developed a detailed Framework for Community/Stakeholder Engagement and it is expected that health service providers will familiarize themselves with their LHIN s framework. 24 These frameworks are working documents detailing each LHIN s approach to their mandate for community engagement. While the various strategies are developed to match local capacities, needs and geographic, socio-demographic and health-based communities, there are several commonalities across the LHINs. Among these commonalities are the establishment of regional and/or health-priority oriented advisory bodies and work groups. The following is sample of a community engagement process within the Central East LHIN: 24 These are found on each LHIN s website. See Appendix for the Central LHIN Stakeholder Engagement Strategy as an example. This document contains additional tools and techniques for engagement under the heading, Expectations for Health Service Providers Concerning LHIN Community Engagement. 19